今日の臨床サポート

頭部白癬

著者: 常深祐一郎 埼玉医科大学 皮膚科

監修: 戸倉新樹 掛川市・袋井市病院企業団立 中東遠総合医療センター 参与/浜松医科大学 名誉教授

著者校正/監修レビュー済:2020/09/03
患者向け説明資料

概要・推奨   

  1. 頭部白癬の診断に際しては鏡検を行うことを強く推奨する(推奨度1
  1. 頭部白癬を疑う場合、真菌培養を行うことを強く推奨する(推奨度1)
  1. 頭部白癬の患者には、経口抗真菌薬による治療が強く勧められる(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
常深祐一郎 : 講演料(エーザイ株式会社,科研製薬,佐藤製薬,鳥居薬品,マルホ)[2021年]
監修:戸倉新樹 : 講演料(田辺三菱,サノフィ,マルホ,協和キリン),研究費・助成金など(ノバルティス,レオファーマ)[2021年]

改訂のポイント:
  1. 日本皮膚科学会の皮膚真菌症診療ガイドラインが改訂された。内容に変更はないが、表現等の整合性をとるため一部を修正した。 

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 頭部白癬とは、白癬菌の毛包、毛および被髪頭部皮膚への感染症である。
  1. 2006年の疫学調査によると皮膚科外来初診患者のうち、白癬が12%であり、そのうち0.22%が頭部白癬であった[1]
  1. 2016年の疫学調査では、白癬のうち0.45%が頭部白癬であった[2]
  1. 小児や児童に好発し、さらに成人にも生じるため、どの年齢、性別にも起こり得る疾患である。
  1. 自分の足白癬や爪白癬よりの感染のほか、家族や友人など他人からの感染、動物や土壌からの感染もある。
  1. 湿疹などと誤診してステロイド外用を行うと悪化する。
問診・診察のポイント  
  1. 頭部を視診する。頭髪をかき分けて皮膚や毛包をよく観察する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Yoshihiro Sei
雑誌名: Med Mycol J. 2012;53(3):185-92. doi: 10.3314/mmj.53.185.
Abstract/Text An epidemiological survey of dermatomycoses and the causative fungus flora of dermatomycoses in Japan for 2006 was made on a total number of 63,029 outpatients who visited 16 dermatological clinics throughout Japan. The results were as follows. 1) Dermatophytosis was the most prevalent cutaneus fungal infection (7,582 cases) seen in these clinics, followed by candidiasis (842 cases) and then Malassezia infections (283 cases). 2) Among dermatophytoses, tinea pedis was the most frequent (4,779 cases : male 2,358, female 2,241), then in decreasing order, tinea unguium (2,582 cases : male 1,376, female 1,206), tinea corporis (564 cases : male 341, female 223), tinea cruris (309 cases : male 254, female 57), tinea manuum (145 cases : male 92, female 53), and tinea capitis including kerion (17 cases : male 12, female 5). 3) Tinea pedis and tinea unguium are seen to increase in the summer season, among the aged population. When compared to the last survey 2002 by clinical form, t. unguium patients increased 459 cases. 4) As the causative dermatophyte species, Trichophyton rubrum was the most frequently isolated among all dermatophyte infections except tinea capitis. Microsporum canis was slightly increased. M.gypseum and Epidermophyton floccosum are small number. T.tonsurans was increased up to 37 cases. 5) Cutaneous candidiasis was seen in 842 cases (305 male, 537 female). Intertrigo (298 cases) was the most frequent clinical form, followed by erosion interdigitalis (136 cases), oral candidiasis (135 cases), onychia et paronychia (108 cases), genital and diaper candidiasis in total (88 cases). 6) Tinea versicolor was seen in 175 cases. Malassezia folliculitis were collected 108 cases, 63 cases are reported from one clinic.

PMID 23149353  Med Mycol J. 2012;53(3):185-92. doi: 10.3314/mmj.53.185・・・
著者: Harunari Shimoyama, Yoshihiro Sei
雑誌名: Med Mycol J. 2019;60(3):75-82. doi: 10.3314/mmj.19.007.
Abstract/Text We report here the results of the 2016 epidemiological survey of dermatomycosis in Japan. In total, 6,776 cases were analyzed as follows: dermatophytosis, 5,772 cases (85.2%); candidiasis, 757 cases (11.2%); Malassezia infection, 235 cases (3.5%); and other fungal infections, 11 cases (0.2%). In dermatophytosis, tinea pedis was the most frequent (3,314 cases: male, 1,705; female, 1,609), followed by tinea unguium (1,634 cases: male, 766; female, 868), tinea corporis (423 cases: male, 241; female, 182); tinea cruris (316 cases: male, 242; female, 74); tinea manuum (58 cases: male, 29; female, 29); tinea capitus, Celsus' kerion (26 cases: male, 19; female, 7); and tinea barbae (1 case: male, 1). The most frequent pathogen was Trichophyton rubrum. In candidiasis, candidal intertrigo was the most frequent (181 cases: male, 98; female, 83), followed by oral candidiasis (165 cases: male, 84; female, 81), genital candidiasis (119 cases: male, 45; female, 74), diaper candidiasis (113 cases: male, 49; female, 64), erosio interdigitalis (63 cases: male, 13; female, 50), onychomycosis (41 cases: male, 17; female, 24), onychia et paronychia (28 cases: male, 2; female, 26), and angular cheilitis (23 cases: male, 6; female, 17). Although the number of cases varied depending on the role of each cooperating medical institution in the area and on population composition, no significant differences in the frequencies of clinical types were observed.

PMID 31474694  Med Mycol J. 2019;60(3):75-82. doi: 10.3314/mmj.19.007.・・・
著者: L A Drake, S M Dinehart, E R Farmer, R W Goltz, G F Graham, M K Hordinsky, C W Lewis, D M Pariser, J W Skouge, S B Webster, D C Whitaker, B Butler, B J Lowery, B E Elewski, M L Elgart, P H Jacobs, J L Lesher, R K Scher
雑誌名: J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):290-4. doi: 10.1016/s0190-9622(96)80137-x.
Abstract/Text
PMID 8642096  J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):290-4. doi: 10.・・・
著者: L C Fuller, R C Barton, M F Mohd Mustapa, L E Proudfoot, S P Punjabi, E M Higgins
雑誌名: Br J Dermatol. 2014 Sep;171(3):454-63. doi: 10.1111/bjd.13196.
Abstract/Text
PMID 25234064  Br J Dermatol. 2014 Sep;171(3):454-63. doi: 10.1111/bjd・・・
著者: M Jahangir, I Hussain, M Ul Hasan, T S Haroon
雑誌名: Br J Dermatol. 1998 Oct;139(4):672-4.
Abstract/Text In this randomized, double-blind study, the efficacy and safety of oral itraconazole (n = 28) and terbinafine (n = 27), each given for 2 weeks, was compared in patients with tinea capitis. Trichophyton violaceum was the major pathogen in both groups (82.1% and 88.9%, respectively). The final evaluation at week 12 showed a cure rate of 85.7% and 77.8%, respectively (P > 0.05). Adverse events noted were mild and did not warrant discontinuation of therapy.

PMID 9892912  Br J Dermatol. 1998 Oct;139(4):672-4.
著者: S Deng, H Hu, P Abliz, Z Wan, A Wang, W Cheng, R Li
雑誌名: Mycopathologia. 2011 Nov;172(5):365-72. doi: 10.1007/s11046-011-9438-2. Epub 2011 Jun 24.
Abstract/Text OBJECTIVE: To compare the efficacy and safety of terbinafine with griseofulvin in the treatment of tinea capitis in Western China.
METHODS: Children (2-14 years of age) with clinically diagnosed and potassium hydroxide microscopy-confirmed tinea capitis were randomized into three groups: group GRI4 received 4 weeks of griseofulvin; group TBF2 received 2 weeks of terbinafine; and Group TBF4 received 4 weeks of terbinafine. Clinical and mycological evaluations were done in 0, 2, 4, and 8 weeks and 1 year after therapy started. The isolated pathogenic fungi were evaluated for in vitro susceptibility by detecting the minimal inhibitory concentration (MIC) against terbinafine, griseofulvin, itraconazole, and ketoconazole.
RESULTS: The clinical effectiveness rate of GRI4, TBF2, and TBF4 were 100% (95% CI-confidence interval: 82-100%), 96.3% (95% CI: 81-100%), and 100%(95% CI: 85-100%), respectively, at week 8 and 100% after 1 year for the 3 groups; clinical cure rates were 84.2%(95% CI: 77-99%), 85.2%(95% CI: 71-98%), and 78.3%(95% CI: 61-95%), respectively, at week 8 and 100% after 1 year for all agents; mycological cure rates were 100%(95% CI: 74-100%), 95.0%(95% CI: 74-100%), and 94.1%(95% CI: 50-93%) at week 8 and 100% after 1 year for the 3 groups. In vitro, all patient-derived cultures were sensitive to the four antifungal agents.
CONCLUSION: Data from the clinical trial and in vitro antifungal activity indicated that terbinafine is efficacious and well tolerated in the treatment for Trichophyton infections (T. violaceum; Arthroderma vanbreuseghemii; and T. tonsurans) of the scalp, i.e., a 2- to 4-week course of terbinafine is as effective as a 4-week course of griseofulvin; in fact, a 2-week course of terbinafine is sufficient. Terbinafine is an effective alternative to griseofulvin against tinea capitis of Trichophyton infections.

PMID 21701791  Mycopathologia. 2011 Nov;172(5):365-72. doi: 10.1007/s1・・・
著者: H Cáceres-Ríos, M Rueda, R Ballona, B Bustamante
雑誌名: J Am Acad Dermatol. 2000 Jan;42(1 Pt 1):80-4.
Abstract/Text BACKGROUND: Griseofulvin has been used for many years in the treatment of tinea capitis. Increase in resistance to this medication has led to a search for new therapeutic alternatives.
OBJECTIVE: Our purpose was to evaluate the therapeutic efficacy of terbinafine in comparison with griseofulvin in the treatment of tinea capitis.
METHODS: We performed a double-blind, randomized, prospective evaluation of 50 patients with a clinical and mycologic diagnosis of tinea capitis. One group received 4 weeks of terbinafine followed by 4 weeks of placebo. The other group received 8 weeks of griseofulvin. We evaluated 5 clinical parameters. Mycologic examinations were performed at baseline and at the end of weeks 8 and 12.
RESULTS: Patients' ages ranged from 1 to 14 years. Fifty-four percent were girls and 46% were boys. Mycologic examinations disclosed Trichophyton tonsurans in 74% of patients and Microsporum canis in 26%. At week 8, the griseofulvin-treated group showed a cure rate of 76%, and the terbinafine-treated group 72%. At week 12, the efficacy of griseofulvin decreased to 44%, whereas the efficacy of terbinafine was 76%.
CONCLUSION: Terbinafine constitutes an alternative for the treatment of tinea capitis. Recurrences were less frequent. No significant side effects were reported.

PMID 10607324  J Am Acad Dermatol. 2000 Jan;42(1 Pt 1):80-4.
著者: A K Gupta, P Adam, N Dlova, C W Lynde, S Hofstader, N Morar, J Aboobaker, R C Summerbell
雑誌名: Pediatr Dermatol. 2001 Sep-Oct;18(5):433-8.
Abstract/Text Tinea capitis is a relatively common fungal infection of childhood. Griseofulvin has been the mainstay of management. However, newer oral antifungal agents are being used more frequently. A multicenter, prospective, randomized, single-blinded, non-industry-sponsored study was conducted in centers in Canada and South Africa to determine the relative efficacy and safety of griseofulvin, terbinafine, itraconazole, and fluconazole in the treatment of tinea capitis caused by Trichophyton species. The regimens for treating tinea capitis were griseofulvin microsize 20 mg/kg/day x 6 weeks, terbinafine [> 40 kg, one 250 mg tablet; 20-40 kg, 125 mg (half of a 250 mg tablet); < 20 kg, 62.5 mg (one-quarter of a 250 mg tablet)] x 2-3 weeks, itraconazole 5 mg/kg/day x 2-3 weeks, and fluconazole 6 mg/kg/day x 2-3 weeks. Patients were asked to return at weeks 4, 8, and 12 from the start of the study. Griseofulvin was administered for 6 weeks and the final evaluation was at week 12. Terbinafine, itraconazole, and fluconazole were administered for 2 weeks and the patient evaluated 4 weeks from the start of therapy. At this time, if clinically indicated, one extra week of therapy was given. There were 200 patients randomized to four treatment groups (50 in each group). At the final evaluation at week 12, the number of evaluable patients were griseofulvin, 46; terbinafine, 48; itraconazole, 46; and fluconazole, 46. Patients who discontinued therapy or were lost to follow-up were griseofulvin, 1/3; itraconazole, 0/4; terbinafine, 0/4; and fluconazole, 0/4. The causative organisms were Trichophyton tonsurans and T. violaceum species. Patients were regarded as effectively treated at week 12 if there was mycologic cure and either clinical cure or only a few residual symptoms. Effective treatment was recorded in, intention to treat, griseofulvin (46 of 50, 92.0%), terbinafine (47 of 50, 94.0%), itraconazole (43 of 50, 86.0%), and fluconazole (42 of 50, 84.0%) (p=0.33). Adverse effects were reported only in the griseofulvin group (gastrointestinal effects in six patients). Discontinuation from therapy due to adverse effects occurred only in the griseofulvin group (nausea in one patient). For the treatment of tinea capitis caused by the Trichophyton species, in this study, griseofulvin given for 6 weeks is similar in efficacy to terbinafine, itraconazole, and fluconazole given for 2-3 weeks. Each of the agents has a favorable adverse-effects profile.

PMID 11737692  Pediatr Dermatol. 2001 Sep-Oct;18(5):433-8.
著者: S López-Gómez, A Del Palacio, J Van Cutsem, M Soledad Cuétara, L Iglesias, A Rodriguez-Noriega
雑誌名: Int J Dermatol. 1994 Oct;33(10):743-7.
Abstract/Text BACKGROUND: Tinea capitis is a fungal infection in which topical therapy is often unsuccessful. Griseofulvin has been considered to be a first-line therapy. Other antifungal agents are the azole derivatives. Among these, itraconazole was compared with griseofulvin in children in a double-blind study.
PATIENTS AND METHODS: Thirty-four children and one adult with clinical signs and symptoms of tinea capitis and with positive culture and microscopy for dermatophytes have been included in a double-blind comparison between itraconazole, 100 mg daily, and ultramicronized griseofulvin, 500 mg daily. Both drugs were given for 6 consecutive weeks. The final evaluation was made 8 weeks after the end of treatment to allow the hairs to regrow. Seventeen itraconazole- and 15 griseofulvin-treated patients received the complete 6-week treatment course. Fifteen of these 17 itraconazole patients and 14 of the 15 griseofulvin patients had infections caused by Microsporum canis. Fifteen of 17 patients were cured by itraconazole (88%) and 15 of 17 patients by griseofulvin (88%). One of the patients who discontinued griseofulvin therapy after 4 weeks was clinically and mycologically cured. Two of the original 17 griseofulvin patients discontinued therapy because of vomiting. None of the itraconazole-treated children experienced side effects.
CONCLUSIONS: Itraconazole is the first azole derivate that matches griseofulvin for the treatment of tinea capitis in children. The drug also appears to be better tolerated than griseofulvin.

PMID 8002149  Int J Dermatol. 1994 Oct;33(10):743-7.
著者: P J Honig, G L Caputo, J J Leyden, K McGinley, S M Selbst, A R McGravey
雑誌名: Pediatr Dermatol. 1994 Mar;11(1):69-71.
Abstract/Text Therapy for kerions was evaluated by randomly assigning 30 patients to one of four treatment groups: group A griseofulvin, group B griseofulvin plus erythromycin, group C griseofulvin plus prednisone, and group D griseofulvin, erythromycin, and prednisone. Data indicate that antibiotic and steroid therapy, in addition to griseofulvin, may reduce scaling and pruritus, but does not reduce the time it takes for kerions to flatten.

PMID 8170855  Pediatr Dermatol. 1994 Mar;11(1):69-71.
著者: I Hussain, F Muzaffar, T Rashid, T J Ahmad, M Jahangir, T S Haroon
雑誌名: Med Mycol. 1999 Apr;37(2):97-9.
Abstract/Text Glucocorticoids are often recommended along with oral antifungals in the treatment of kerion celsi. In this randomized study, the efficacy of combination therapy with oral griseofulvin and oral prednisolone (n =17) was compared to oral griseofulvin alone (n=13) in the treatment of kerion celsi. Both groups were treated with oral griseofulvin for 8 weeks whereas oral prednisolone was given in tapering doses for 3-4 weeks to the first group only. The final evaluation at week 12 showed a cure rate of 100% in both groups without any significant difference in terms of clinical or mycological cure (P>0.05). No adverse events were noted in either group. In our opinion the combination of oral prednisolone with griseofulvin does not result in additional objective or subjective improvement compared to griseofulvin alone in cases with kerion celsi.

PMID 10361264  Med Mycol. 1999 Apr;37(2):97-9.

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